Case Report
A 53-year-old man came to our center. He complained of chest pain and shortness of breath for 9 days. Computed tomography (CT) scan showed an aortic arch aneurysm with a PAU in the descending aorta, right pleural effusion and right lower lobe atelectasis (Figure 1A, 1B). The PAU was detected in the descending aorta at about 100 mm from the left subclavian artery on CT scan. We had taken active medical treatment for him, including anti-infection, red blood cell transfusion, analgesia, anti-hypertension. 10 days later, coronary CT scan showed that the number of PAU increased and diameter of PAU elevated (Figure 1C). And he underwent open surgery one day later.
Under hypothermic circulatory arrest, we performed TAR with a four-branched vascular graft (28×90mm; Terumo, Vascutek Limited, Renfrewshire, UK) after a FET stent (28×120mm; Cronus, MicroPort Endovascular Shanghai Co, Ltd, China) was deployed into the descending aorta under direct vision. After TAR with FET, the arterial pressure of the left radial artery was higher than that of the left dorsalis pedis, with a difference of about 40 mmHg. We performed aortography via the right femoral artery. However, it was very difficult for the guidewire to move forward. And aortography only showed the narrow thoracic aorta resembled a thin line (Figure 2A). Then we had to perform antegrade aortography via one branch stump of the vascular graft. Only thoracoabdominal aorta, bilateral intercostal arteries and lumbar arteries could be found from the scan, while the celiac axis, superior mesenteric artery, and renal arteries disappeared (Figure 2B). We comprehensively analyzed that the tip of the FET had been inserted into the PAU and caused iatrogenic aortic dissection. The true lumen of thoracoabdominal aorta was totally obliterated and viscera were ischemic. We performed ascending aorta-right femoral artery bypass at once, but the true lumen of aorta did not dilate. Then we performed endovascular thoracoabdominal aortic fenestration to connect the true lumen and the false lumen (Figure 2C). And a stent graft (28×80mm; Valiant, Medtronic Vascular, Santa Rosa, CA, USA) was retrogradely deployed to the descending aorta to restore the perfusion of the true lumen (Figure 2D). After that, the radial artery and the dorsalis pedis pressures were equal. But these procedures were complicated, and it took about four hours to complete these procedures. During this period, the visceral including liver, intestine and kidneys were ischemic. Progressive lactic acidosis developed during operation. The patient received bedside hemofiltration intraoperatively. After he was returned to the intensive care unit, the hemodynamics deteriorated quickly. And the patient died of multiorgan failure on the 1stpostoperative day.